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Full text of "United States Navy Medical News Letter Vol. 32 No. 6, 19 September 1958"

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NftvMed 369 







Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 32 



Friday, 19 September 1958 



No. 6 



TABLE OF CONTENTS 



Hazards of Scuba Diving 2 

Bagassosis 6 

Treatment of Parenchymal Tuberculosis 8 

Diagnostic Criteria of Congenital Hypothyroidism 10 

Generalized Cytomegalic Inclusion Disease 12 

Late Local Recurrent Carcinoma of the Breast , 13 

Health and Safety in Transportation 15 

Change s in Thre shold Limit Value s 21 

Industrial Medicine 21 

Letters from General Pate and General Hays 23 

From the Note Book 24 

Voluntary Retirement ^ 26 

Board Certifications 26 

Recent Research Reports 27 

DENTAL SECTION 

Facilities and Materiel Programs 29 

High-Speed Dental Radiographic Film 29 

Induction and Separation Examinations 29 

RESERVE SECTION 

New Component in Selected Reserve Forces 30 

Informative Publications 31 

PREVENTIVE MEDICINE SECTION 

Influenza 31 

Chest Roentgenogram and Related X-Ray Radiation Effects 35 

What You Should Know about the Use of Turn Signals 38 



Medical Neva's Letter, Vol. 32, No. 6 



Hazards of Scuba Diving 



n 



The industrial physician now must add at least a rule-of-thumb know- 
ledge of diving medicine to his lists of talents. Since the development of 
barometric compensated demand valves for increased pressures, the prac- 
tice of diving with self-contained equipment has spread all over the world, 
but nowhere has it caught the public fancy as in the United States. Diving is 
no longer only a sport of the tropical seashore. The diving equipment has 
been proved useful for many kinds of umderwater work, not the least of which 
is geological searching. 

If for no other reason than that the company recreation association may 
be sponsoring an aquatic sports club, the industrial physician has a need to 
know. 

First of all, one must distinguish between the skin diver — who is just 
that, a swimmer who dives — and the diver. It matters not that the skin diver 
wears foot fins to aid his swimming, goggles or face mask (preferably the 
latter) to give him better underwater vision or uses a snorkel (breathing 
tube). He is a swimmer and can stay submerged only so long as he can hold 
his breath. He is subject chiefly to the hazards of swimnning. 

Before investing money in any diving outfit, the individual should con- 
sider the matter of physical fitness to dive. Diving is not a form of hydro- 
therapy in the usual sense of that term. It is hard work — nnuch more stren- 
uous than walking. vVhile the surface swimmer is able to adjust his energy 
expended to a comfortable level, this is not true for the diver. Under water, 
even the exertion of breathing is considerable. This is due to the resistance 
of the valves and the airways, and the increased density of the air. In addition, 
there is the exertion of swimming. No hard and fast rule can be laid down, 
but it seems reasonable that a person with active disease of the pulmonary 
or cardiovascular systems should not engage in any strenuous sport, including 
this one. Air travelers know thay may encounter difficulty in equalizing 
pressure in the ears and sinuses with changes in altitude. These same indi- 
viduals often do not realize that the relative pressure differential produced 
by altitude changes of hundreds of feet may be produced by a foot or two 
difference in underwater depth. Certainly, those who do not have the ability 
to equalize pressure in their ears and sinuses would do well to find another 
sport. Chronic ear infections are not likely to improve. Perforated ear 
drums invite infection with possible disastrous results on hearing ability. 
Aside from the liability of flare-ups of infection, there is the more immediate 
danger of extreme dizziness caused by water entering the ear and producing 
the reaction of the caloric test of vestibular function. The dizziness is bad 
enough, but when accompanied by nausea, it may produce an underwater 
situation ending fatally. 

In addition to the considerations of physical fitness, there is the matter 
of self-confidence in the water. This is more than being a good swimmer. 



Medical News Letter, Vol, 32, No. 6 



although that is highly desirable. The underwater world is fascinating, but 
it is, for man, an unnatural and hostile environment. Emergencies and 
surprises can, and do, arise frequently in this sport. Life or death hangs 
in the balance for the moment. Nothing else means so much in that instant 
as calm deliberate evaluation of the situation based on self-confidence. This 
composure is not gained hastily nor by chance. Sport diving is not for those 
who are novices at water sports nor for the physically soft or unsound. 

The sportsman diver uses some form of self-contained underv/ater 
breathing apparatus (abbreviated to "scuba" for convenience) which supplies 
him with a breathing medium from a compressed supply carried in a flask. 
This is an appropriate place to condemn any misguided and dangerous 
attempt to use under water a rescue breathing or smoke type apparatus hav- 
ing a demand valve. The demand valves of this type of equipment simply are 
not expected to operate adequately under the increased ambient pressures 
encountered in diving; not even at relatively shallow depths. This is the 
chief objection to the use of demand valves salvaged from aviator's oxygen 
eqmpment. Do not use anything but equipment designed for this purpose and 
backed by the good name of a reputable manufacturer. 

Another basic rule of diving safety is, never use oxygen as a breathing 
medium. About a year ago, a letter was received from a physician in the 
Middle West asking what chemical was used in a diving outfit to absorb car- 
bon dioxide. Being aware that physicians often make mistakes because of 
being partly informed, this inquiry aroused the suspicion that this doctor 
was making an oxygen, closed-circuit type scuba in the belief that a small 
flask of oxygen could be used safely to extend his submerged time. There is 
such equipment used by experts for special military missions. Their use 
can be reasonably safe in the hands of especially indoctrinated, experienced 
divers, but they are never used by choice, only out of necessity. They clearly 
are not for the sportsman diver. 

A cautious answer was composed for the doctor. It was suggested 
that a canister design for diving equipment is not the same as for gas masks, 
that moisture can ruin the effectiveness of the carbon dioxide absorbent, that 
failure of the absorbent can result in "shallow water black-out" {presumably 
carbon dioxide toxicity) and unconsciousness leading to drowning. And, if 
none of these happened, he could always worry about oxygen convulsions. 
The Navy tests candidates for diver school by having them breathe oxygen 
from a mask for 30 minutes while at a pressure equivalent to being 60 feet 
deep in the water. An appreciable number fail this test. Astonishingly few 
physicians seem to have heard of this convulsant effect of oxygen. This rule 
is worth repeating— never use an oxygen outfit. 

Now the confident swimmer is equipped with a well designed, open cir- 
cuit, air -supplied, self-contained underwater breathing apparatus. The open 
circuit type is specified because this eliminates the carbon dioxide absorbent 
canister required in closed circuits and removes the hazard of failure of 



Medical News Letter, Vol. 32, No. 6 



n 



this unit. This equiprnent is not cheap. It deserves good care and main- 
tenance. The diver should learn to service and maintain his own equipment. 

The proper care of such equipment can be learned in part by reading 
the literature supplied with the equipment. However, nothing written in sales 
promotion pamphlets equals the lessons that can be imparted by one who has 
learned by an experience he has survived. For this reason, the novice 
sport diver should join an organized diving club. It would be wise to affil- 
iate with a club associated with an organization known to have a sound, con- 
servative water- sport program rather than with a collection of "aquatic hot- 
rodders. " Although not an infallible test, those clubs having grown past 
adolescence in this sport, recognize that the setting of diving records is a 
temptation to foolhardiness. Novices should avoid such groups for their own 
safety and the sake of the sport's good reputation. A good club will sponsor 
activities for divers at various levels of proficiency. Because this is some- 
thing new, as it was to all the others at some time, there should be no reluc- 
tance in lining up with the beginners. Training prog ranis must be adjusted to 
the time, place, and facilities available. But sometime in the course of any 
good training program there are certain things that will be heard over and 
over. Among them are: 

Don't dive alone. Underwater emergencies can arise when least ex- 
pected from failure of equipment, from illness of the diver, from under- 
water hazards — living things or mechanical things. One diving buddy 
can look out for the other. 

Use a buddy-line. Whenever diving at night or in conditions of poor 
visibility, a diver can find his buddy if they are tied to each other. CDR 
Douglas Fane, the daring leader of underwater demolition teams wrote on 
a casualty report, "Another life saved by the buddy system. " This en- 
dorsement should be testimony enough for anyone. 

Don't try to set records. The world's deepest diver was last seen 
going down. The object is to come back, not to see how deep one can go. 

Easy does it . After all, it is a sport. Exhaustion is the door to dis- 
aster. A tired man does not think well. AH people do not swim equally 
well nor have the same endurance. A less able swimmer can exhaust 
himself trying to keep up with a more able buddy and once exhausted he 
is easy prey in an emergency. He may not only lose his own life, but 
also may cause his buddy to lose his in rescue efforts. Take turns at 
being the leader so each diver frequently has a chance to set the pace. 

Never forget to exhale when coming up. This fundamental rule has to 
do with Boyle^s Law of the behavior of gases. At constant temperature, 
the volume of a given mass of gas varies inversely as the absolute pres- 
sure exerted on it. A diver 33 feet deep in the water (two atmospheres 
absolute pressure) whose chest is filled with air would, if he held his 
breath, have two chest fulls when he reached the surface (one atmosphere 



Medical News Letter, Vol. 32, No. 6 



absolute). Obviously, his ribs keep his lungs from expanding to double 
their size so the pressure is not equal inside the lungs and outside the 
body. This pressure gradient is exerted across the alveolar membrane. 
A pressure gradient such as this can force air out of the alveoli, into the 
interstitial tissues (emphysema) and even into the vascular tree {air em- 
bolism). Fatal air embolism has been known to occur from quite shallow 
depths {10-15 feet). While emphysema may be only bothersome and dis- 
tressing, air embolism is an immediate critical emergency. The only 
adequate treatment when air embolism causes unconsciousness is recom- 
pression to a depth sufficient for treatment (l65 feet). Unfortunately, 
facilities for recompression are expensive and require knowledgeable 
operators. Very few civilian owned recompression facilities exist. The 
Navy has such facilities distributed along the sea coasts to meet its needs. 

Sport divers who do not set out to establish records are not ordinarily 
liable to encounter problems of decompression sickness unless they dive deep, 
stay down for long periods, or what is more often the mistake, make several 
dives in a day. The sport is so fascinating it creates a strong temptation to 
go deeper and stay longer. The manufacturers of the better known equipment 
have tried to avoid this problem by controlling the size of the compressed air 
flask. However, popular demand has created a market for outfits with more 
than one flask. There is only one way to avoid this problem and that is to never 
exceed the no -compre s sion schedule according to the Table accompanying this 
article. One dive a day made within these limits is relatively safe. 

No Decompression Dive Schedules * 

Deepest Depth of Dive "Bottom Time"** 

in Feet in minutes 

35 310 

40 200 

50 100 

60 60 

70 50 

80 40 

90 30 

100 25 

110 20 

120 15 

130 10 

140 10 

150 5 

160 5 



Medical News Letter, Vol. 32, No. 6 



* The foregoing schedule, based on experimental data collected by the 
U. S. Navy Experimental Diving Unit, Washington D. C. , will appear in a 
revision of the Navy Diving Manual now in preparation. It is based on a 
rate of ascent of 60 feet per minute. 

** "Bottom time" commences when the diver leaves the surface and 
ends when he leaves the bottom to ascend directly to the surface. 

(Harry J. Alvis CAPT MC USN, Hazards of Diving with Self-Contained Under- 
water Breathing Apparatus: Indust. Med., ZTj 389-391, August 1958) 

****** 
Bagassosis 

Bagasse is the fibrous' material renraaining after the sugar -containing 
juice has been expressed from sugar cane. The word was first applied in 
France to the refuse from olive oil mills. 

Bagassosis, or bagasse disease of the lungs, is a disorder resulting 
from the inhalation of bagasse dust. Typically, it is an acute pneumonitis 
or bronchiolitis which is often associated with roentgenographic features 
resennbling miliary tuberculosis. Dyspnea is the nriost characteristic symp- 
tom, although cough, hemoptysis, fever, weakness, and weight loss are often 
present. Complete recovery usually takes place after a few weeks or months. 

In spite of the fact that bagassosis is unquestionably caused by the inhal- 
ation of bagasse dust, the specific physiopathological mechanism involved in 
the relationship has never been clearly defined. The disease has been var- 
iously attributed to a specific irritant property of the bagasse fiber itself, 
to its silica content, to allergy, to microorganisms present in the dust, and 
to all combinations of these factors. 

From the discussion, it is obvious that many factors nnay be involved 
in the etiology of bagassosis; at present none of the proposed mechanisms 
seem to satisfy all objections. Further studies are needed with particular 
attention directed toward the role of microorganisms of ordinarily low viru- 
lence. Additional pathological information would be highly desirable and 
might help to clarify the puzzling etiology of this disease, but it seems likely 
that appropriate materials will be difficult to obtain. 

The occupations associated with exposure to bagasse dust are those 
involving heavy manual labor. This accounts for the occurrence of the dis- 
ease almost exclusively in men 20 to 45 years of age. No racial differences 
have been observed. Working conditions favorable to the contraction of the 
disease include a dusty atmosphere, usually in a poorly ventilated space, 
and almost invariable contact with dry bagasse. 

A review of the reported cases of bagassosis immediately innpresses 
one with the consistency of the clinical picture. In most instances, after 



Medical News Letter, Vol. 32, No. 6 



exposure to the dust for periods of a few weeks to a few months, symptoms 
appear over a space of several days. Cough, exertional dyspnea, and slight 
fever are usually the initial complaints. Hemoptysis of a mild degree is 
rather common, but frank pulmonary hemorrhage is rare, if it occurs at all. 

As the disease progresses, dyspnea usually dominates the clinical 
picture and soon becomes incapacitating. Cyanosis may appear in more 
severe cases. Weakness is often prominent and may be associated with anor- 
exia and loss of weight. These latter symptoms sometimes antedate all others 
and the amount of weight lost is at times impressive. 

Fever is usually slight to moderate, but temperature elevations as high 
as 104° F. are observed in the more severe cases. Other symptoms may 
include night sweats, chilly sensations, and retrosternal pain. True chills 
are less common. Pleuritic pain is absent. 

Physical examination may reveal little more than various degrees of 
dyspnea and, possibly, cyanosis. The pulse rate is elevated in proportion 
to the temperature. Diffuse or localized crepitant rales can usually be heard 
over the lung fields and the second pulmonic heart sound may be accentuated. 
A slight or moderate blood leukocytosis is usually present, but eosinophilia 
is not observed. 

The vast majority of patients tend to iniprove spontaneously when they 
are removed from contact with the offending agent. Symptoms gradually 
abate in a few weeks and complete recovery usually takes place in I to 6 
months, although in sonne cases the patient may not feel entirely well for a 
year or more. The abnormal x-ray findings gradually resolve and, as a 
rule, no trace of the disease remains after 2 to 6 months, but some impair- 
ment of pulnnonary function may be detected for longer periods. 

Four of the fifty-three patients reported in the literature have died of 
bagassosis, representing a mortality rate of about 7.5%, However, this 
figure is probably not a true one and should be much lower because many 
milder cases of the disease have undoubtedly escaped medical attention. 

The diagnosis of bagassosis is based on the occupational history, the 
characteristic clinical and roentgenographic picture, the usual benign course, 
and the exclusion of other disorders. Miliary tuberculosis offers the chief 
problem in differential diagnosis. However, any of the vast group of diseases 
which may be associated with miliary lesions in the lung must be considered 
and excluded. (Buechner, H. A. , et al. , Bagassosis - A Review with Further 
Historical Data, Studies of Pulmonary Function, and Results of Adrenal 
Steroid iherapy: Am. J. Med., XXV : 2 34 -.24 5. August 1958) 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

^ jAc jiAe 3{c sk jic 



8 Medical News Letter, Vol. 32, No. 6 



Treatment of Parenchyrrtal Tuberculosis 

This study concerns the exploration of an entirely new approach in 
the chemotherapy of parenchymal tuberculosis: the endobronchial route. 
This concept is relatively new and few references are to be found in the lit- 
erature. Before going into the details of its clinical aspects, certain basic 
anatomico -physiological as well as pathological phases of the fate of particu- 
late matter within the lung are outlined. Special reference is made to the 
tubercle bacillus as well as the antituberculosis characteristics of several 
drugs for a better understanding of the rationale of this type of therapy. 

Studies of the fate of particulate substances, including the tubercle 
bacillus introduced into the respiratory channels, show a definite reaction 
on the part of the host to such invasion. The portion of this nnatter not immed- 
iately removed by cough penetrates the air passages and is carried to their 
finest subdivisions where it is subjected to reactions brought about by the pro- 
tective forces indigenous to normal tissues. Phagocytosis is the first to 
function, but is limited to particles less than 10 microns in size. The larger 
particles are not engulfed; they are promptly removed through the airways by 
the usual excretory function of entrapment in mucous secretions, ciliary 
motion, molding by the spiral bronchial nnusculature, and the expellent force 
of cough. Three cells — the polymorphonuclear leukocyte, the mononuclear 
alveolar cell, and the mononuclear cell which is believed to come from the 
blood — are the phagocytes concerned in removing particulate matter from the 
parenchyma; this is done by way of the lymphatics. One mechanism is by way 
of the superficial lymphatics which follow the first radicle of the pulmonary 
vein from the center of the primary lobule to its periphery and then course 
outward to join the subpleural plexus which in turn unite to form the lymph 
vessels that empty into the hilar nodes. The second is by way of the deep 
lymphatics which follow the bronchial and vascular channels towards the 
hilar lymph nodes. Still a third method of excretion through the alveolar 
ducts, bronchioles, and bronchi exists, but does not concern this study 
because it is noncontributory to the concentration of the drug in the paren- 
chyma or lymphatics. 

These observations would indicate that the introduction of particulate 
matter of antituberculosis activity directly into the bronchi would follow the 
same route taken by the tubercle bacillus and thus introduce bacteriostatic 
or bacteriocidal agents directly into foci usually involved by tuberculous 
infections. With such a portal of entry, several advantages are obvious: 
(1) a high focal concentration of the drug may be possible which would re- 
main in the lobe for an indefinite period (oily suspension); (2) phagocytes 
loaded with engulfed drug particles are made bearers of the noxious agent 
to the tuberculous foci proper and, with their death, release a therapeutic 
bomb; (3) bacilli-laden phagocytes will transport only nonviable bacilli to 
new foci because INH — unlike SM — readily penetrates cell membranes in 
effective bacteriostatic or bacteriocidal concentration. 



Medical News Letter, Vol. 32, No. 6 



The patients studied, in this series were not selected, taut were treated 
in sequence as they appeared. All were ambulatory and only the more severely 
ill were confined to bed until the acute symptoms had subsided; but in no 
case for longer than 2 weeks. They are classified on the basis of x-ray 
findings and the severity of this involvemient. All but two were on concomi- 
tant oral INH with conventional dosages. Two pregnancies, two diabetics, 
and one far-advanced unilateral bronchiectasis were the nontuberculous 
associated findings in the series. Two had complicating pleural effusion. 
In addition, two had persistent cavities with pneumothorax failure. One had 
tuberculous bronchostenosis of the left side with a destroyed lung. Two were 
postsurgical positives — one a lobectomy with exudative spread and the other 
an ivalon sponge plombage. The others ranged from acute exudative to the 
chronic fibrocaseous and fibroid types, although in some these phases were 
combined. Many cavities were encountered in the series — sonne single and 
others multiple in the same patient. 

From their observations, the authors believe that the endobronchial 
therapy for pulmonary tuberculosis is indeed specific and apparently inde- 
pendent in its action from any effect of oral therapy. 

The rapid disappearance of fluid in the two cases of effusion complica- 
ting the pulmonary lesions world indicate that this treatment is also effective 
against tuberculous effusions. Bronchoscopic observations with respect to 
secretions show that these are considerably reduced in quantity and modified 
in character following INH instillation, and in many of the patients stopped 
completely within a short interval. Papanicolaou smears showed a rapid 
disappearance of the leukocytes with reversion to a normal cytogram. 

Dosage schedules, because of the pilot nature of this study, were nnore 
or less arbitrary and instillations were generally repeated when it was con- 
sidered that an additional instillation would further effect the regression of 
the lesion. For the same reason, accurate spacing could not be determined 
because the time intervals of effective change and quantitative response of 
the lesion were unknown factors. In general, it would now seem that frona 
one to four instillations are necessary for maximum therapeutic effect 
spaced at 20-day intervals. This arrangement, however, is a mere guide 
and if the lesions persist or recur a second instillation is in order at any 
particular time. 

The amount of the suspension used was generally 10 cc. per lobe and 
for these purposes the lingular division is considered as a separate lobe. 
Multiple instillations, when indicated, are made at the same time. With the 
five -lobe broncho graphic technique, as much as 25-30 cc. of the radiopaque 
suspension may be used. 

Resistance of the tubercle bacillus as judged clinically has not been 
a factor in this study when using the endobronchial instillation, although it 
may be expected when the scope of this technique is enlarged to a greater 
number of cases. (Carabelli, A. A. , The Endoscopic Treatnnent of Parenchymal 
Tuberculosis, A Pilot Study in the Human : Dis. Chest. , XXXIV: 163-178, Aug. 1958) 



10 Medical News Letter, Vol. 32, No. 6 



Diagnostic Criteria of Congenital Hypothyroidism 

It seems clearly evident that the earlier the diagnosis of congenital 
hypothyroidism is established and adequate therapy is begun, the more 
satisfactory is the prognosis. In a series of 49 cretinous patients seen at 
the University Hospital {University of Michigan), the average age at the time 
of diagnosis was 12 months. The authors believe that in most of these cases 
a diagnosis could have been made before 6 months of age. A survey of these 
patients revealed that 54% had at least three prominent symptoms of their 
disease by the end of the first month of life and 75% by the end of the third 
month. At present, there are generally available laboratory studies that can 
confirm a suspicion of congenital hypothyroidism in better thain 90% of cases. 
Most of the pediatric textbooks and more extensive reference works pay little 
attention to the early time of appearance of the several important — although 
nonspecific — synnptoms and, in describing the typical cretin, fail to ennpha- 
size that many of the classical physical findings are relatively late in onset. 
The present detailed study was made in an attempt to define more precisely 
criteria that will lead to an earlier recognition of the condition. 

All of the 49 patients included in this survey have been followed in the 
University Hospital from 1 to over 30 years. Thirty-one of the patients were 
seen by the authors within the past year as part of a study which included a 
carefully obtained interval history in addition to a reevaluation of the original 
history. Both parents, when alive, were interviewed. A genetic evaluation 
was done by a member of the Department of Human Genetics of the University 
Medical School. Psychometric tests were obtained on all of the patients and 
constitute a portion of another report. Special studies were carried out in 
most family groups, including: protein-bound iodine determinations, radio- 
active iodine uptake by the thyroid at 1, 2, and 24 hours, paper chromato- 
graphy of serum butanol-extractable iodine compounds, serum cholesterol 
determinations, and determinations of basal metabolic rate in the parents 
and older children. 

The hospital records of the 18 patients who were not seen as a part of 
the special study were reviewed and a detailed questionnaire was sent to the 
families. 

The age range of the patients at the time of preparation of this report 
was from 12 months to 32 years. All were of the white race, 37 infants 
were born in Michigan, 3 were born outside of Michigan, and the place of 
birth of 9 patients was not known. 

The findings in this group of 49 cretins studied at the University Hos- 
pital are presented in an attempt to find as many criteria as possible that 
will lead to the earliest diagnosis. An analysis of the data leads to the 
following conclusions: 

Important signs of cretinism become apparent by the third month in a 
high percentage of these infants. The moat commonly observed findings in 



Medical News Letter, Vol. 32, No, 6 11 



order of frequency are: lethargy, constipation, feeding problems (including 
slow feeding), choking, failure to gain weight, and lack of interest; respira- 
tory difficulties, umbilical hernia, and skin changes. Three or more of 
these were present in over 50% of the patients by the end of the first month 
and in 75% by the end of the third month. The classical picture of the myx- 
edematous cretin does not emerge until later. 

The cause for delay in diagnosis is difficult to ascertain, but the auth- 
ors believe that two of the most important factors can be attributed to the 
physician. He may wait for the "full-blown" development of cretinism to 
be sure of his diagnosis j he may have had the misconception that the time 
of diagnosis makes relatively little difference in the ultimate prognosis. 
There is enough evidence available at present to prove that this is a grave 
error. 

The incidence of thyroid disease in the fainilies of cretins is greater 
than in the general population. The occurrence of more than one sibling with 
congenital hypothyroidism is not uncommon. It occurred in 9% of families 
in the present series. 

The course of pregnancy and labor resulting in a congenitally hypo- 
thyroid infant is not remarkable in most instances. There is no character- 
istic birth order in congenital hypothyroidism. 

Seventy-five percent of the congenitally hypothyroid children in this 
series were of the athyroid type. Eight percent were born with, or devel- 
oped, goiters in infancy or early childhood. An error in the synthesis of 
the hormone was proven in all but one of the goitrous patients and was prob- 
ably present in the one exception, but tests could not be completed. 

The estimation of the serum protein-bound iodine or butanol extr ac- 
table iodine is the most valuable laboratory test to establish diagnosis because 
of its reliability and the fact that exposure to radioactivity is avoided. This 
last factor is the only serious limitation to the use of l'^^^ uptake by the thy- 
roid which is an equally reliable diagnostic procedure. In goitrous patients, 
and possibly in a small numiber without goiter formation caused by errors 
in synthesis of the thyroid hormone, laboratory determinations in addition 
to those of protein-bound iodine and ll31 uptake may be necessary to estab- 
lish a definite diagnosis. The more exact identification of iodinated com- 
poiinds in the blood is then required. 

The evaluation of bone maturation is a valuable screening device. Every 
patient adequately examined by x-ray for "bone age" had easily measured 
retardation. Without the finding of delay in appearance of ossification centers, 
one can strongly doubt the diagnosis of hypothyroidism. 

The authors believe that the therapeutic trial of thyroid in infants and 
children as a means of diagnosis is no longer a desirable procedure. 

Diagnosis of cretinism usually can be made by 3 months and certainly 
before 6 months of age with the aid of careful history, adequate physical 
examination, and a very few laboratory procedures. (Lowrey, G. H. , et al. , 



12 Medical News Letter, Vol. 32, No. 6 



Early Diagnostic Criteria of Congenital Hypothyroidism - A Connprehensive 
Study of Forty-Nine Cretins: J. Dis. Chil. , 96: 131-142, August 1958) 

****** 
Generalized Cytomegalic Inclusion Disease 

Generalized cytomegalic inclusion disease is systemic, primarily of 
infancy, and characterized by the presence of intranuclear and intra cyto- 
plasmic inclusion bodies in enlarged cells of a variety of viscera. It has 
also been known as generalized salivary gland virus disease, inclusion dis- 
ease, and protozoan cell disease. In 1921, Goodpasture" and Talbot recog- 
nized the abnormal cells as altered tissue cells rather than protozoan organ- 
isms and referred to the changes as "cytomegalia." Apparently, identical 
cells have been encountered incidentally in 10 to 32% of salivary glands, and 
in other organs in 1 to 2% of routine infant autopsies. In certain cases, how- 
ever, a specific salivary gland virus infection exists which probably originates 
in utero and may or may not end fatally. 

Cytomegalic inclusion disease may be divided into four main categories: 
(1) the subclinical variety found in submaxillary glands and other organs at 
autopsy of stillborn or newborn infants dying of other causes; (2) poorly 
understood cases occurring apparently in association with other diseases, 
such as pertussis; (3) postulated cases with mild manifestations and recovery; 
and (4) the systemic or generalized variety which is usually lethal. 

In children under 2 months of age, the condition is usually primary 
and fatal. In older children, it may be prinnary, but more often is associated 
with another disease and plays a minor role. It has been reported in an elder- 
ly female with vitamin A deficiency and malnutrition, in an adult male with 
leukemia who had received an antifoiic acid drug which is known to affect 
cellular metabolism, and in guinea pigs after 3 weeks of aminopterin therapy. 

The clinical picture is extremely varied and depends on the degree and 
site of involvement as well as the resistance of the host. The usual mani- 
festation is a hematologic disturbance or jaundice in the newborn infant, full- 
term or premature. Thrombocytopenia nnay occur with accompanying petech- 
ial hemorrhage and the anen:iia nnay be hemolytic. Hemorrhagic manifestations 
nnay take the form of purpura, hennaturia, melena, hematemesis, or cerebral 
hemorrhage. Hepatosplenonnegaly is often present, but usually not marked, 
and there may be respiratory symptoms suggesting pneumonia. Macrocephaly, 
microcephaly, convulsions, and intracranial calcification have been reported. 
Chorioretinitis has recently been described. 

Antemortem diagnosis of cytomegalic inclusion disease is made most 
readily by demonstration of inclusion cells in the urinary sediment and rarely 
from other epithelial surfaces. Roentgen findings of interest are seen in the 
group manifesting the disease at birth who are clearly victims of salivary 



Medical News Letter, Vol. 32, No. 6 13 



gland virus infection alone. Visible calcification outlining dilated lateral 
ventricles, when it occurs, is probably pathognomomc. 

Changes in the lungs, when present, have not followed a consistent 
pattern. Interstitial pneumonia is usually described pathologically, but 
many cases, especially in the neonatal group, show no roentgen abnormal- 
ities. 

Although salivary gland infection is poorly understood in many sit- 
uations, the neonatal primary form, so-called generalized cytomegalic 
inclusion disease, has emerged as a clear entity. 

The disease is probably acquired transplacentally and may involve a 
few or almost all organ systems. Brain involvement frequently is mani- 
fested by calcification around the lateral ventricles which, if present, is 
virtually diagnostic. Signs of brain atrophy are also commonly seen. 

Marked diffuse bony sclerosis may be demonstrable at birth with 
atrophic changes becoming apparent in later months. These are probably 
nonspecific findings. (Allen, J. H. , Riley, H. D. Jr., Generalized Cyto- 
megalic Inclusion Disease with Emphasis on Roentgen Diagnosis: Radiology, 
71 : 257-261, August 1958) 

Late Ljocal Recurrent Carcinoma of the Breast 

This article is a report on a group of patients who had carcinoma of 
the breast treated by radical mastectomy and who then had local recurrence 
5 or more years after the initial operation. An effort is made to answer the 
following questions: vVhat is the cause of local recurrence? Why did this 
group of patients survive 5 or more years before the carcinonria recurred 
when, in the great majority of patients, it recurs at a much earlier date? 
How long do patients live after late local recurrence? 

At the Mayo Clinic, in the years 1945 through 1954, there were 202 
cases of locally recurrent carcinoma of the breast following radical mas- 
tectomy. All of these patients were operated on at the Clinic and in all 
cases the original tissue was reviewed and the pathologic diagnosis of car- 
cinonna of the breast was verified. The recurrent lesion developed within 
5 years of the time of the primary operation in 157 cases (78%), and after 
5 years in the other 45 cases (22%); in ten of the latter cases, the recurrent 
lesions developed more than 10 years after operation. The group of 45 cases 
connprises the material of this investigation. 

All 45 patients were women whose ages ranged from 35 to 72 years. 
Nowhere in the study was there evidence to indicate the possible influence 
of early diagnosis; all the primary tumors were not detected at an early 
date. On an average, the primary tumors were not small, nor were symp- 
tonns of linusually short duration. In fact, only 2 3 patients had clinical 



14 Medical News Letter, Vol. 32, No. 6 



symptoms for a period shorter than 6 months. The distribution of tumors 
with respect to grade (Broder's method) was about the same as that of a 
group of ordinary, rian-of -the -mill carcinomas of the breast. Approximately 
half of the patients had axillary metastasis. Twenty-five of the primary 
tumors involved the lateral half of the breast, 12 involved the medial half, 
and 8 were centrally located. However, the lateral tumors were associated 
with axillary metastasis in 44%, while the medial and central tumors were 
associated with such metastasis in 55%. This would seem to imply that the 
medial tumors were of a slightly more progressive nature. Eight of the 20 
medial and central tumors clinically were fixed to the skin in some degree, 
while 14 of the 25 lateral tumors were judged clinically to have involved the 
skin and they grossly appeared to be as far advanced as the luedial tumors. 
Of a total of 22 patients who had axillary metastasis, only 13 had some skin 
fixation. In approximately half of the series, there was clinical evidence of 
skin fixation by the primary tumor. 

The most common form of local recurrence was that of a skin nodule 
located medial to the scar near the sternum. This was true for the tumors 
located in the lateral half of the breast as well as for those located in the 
medial half or centrally. 

The survival period after local recurrence was known in 24 of the 45 
cases studied. The average survival period was approximately 2 years with 
a range of 3 months to 6 years. Ho^weve^, only three patients survived longer 
than 2 and 1/2 years. The average survival periods for patients following a 
local recurrence at 6 years was the same as for those who had a local recur- 
rence at 8, 10, 12, 14, or 16 years (2 years £. 3 months). 

The authors' data on size, grade, and clinical duration of primary 
tumors of the breast closely approximate the average data reported in the 
literature. Any relationship between the grade, size, or clinical duration of 
the primary tumors and the time of local recurrence was not demonstrated. 
Also, there was no evidence to indicate that late recurrences are possibly 
due to an early diagnosis; clinically, 49% of the primary lesions of the breast 
were judged to be fixed to the skin to some extent. This suggests that local 
involvement of the skin by the primary tumor was not related to the time of 
recurrence. 

It is clear that the lymphatic drainage of the breast is in intimate 
relation with that of the overlying skin. Because the incidence of metastasis 
to the axillary nodes is extremely high in patients in whom recurrent lesions 
develop in the skin, it seems probable that retrograde embolization and retro- 
grade permeation from residual carcinoma in the lymphatic system are fre- 
quently responsible for local recurrences. 

In the light of more recent studies on internal mammary nodal metas- 
tasis from carcinoma of the breast, the authors believe it reasonable to 
postulate that at least half of the medial and central lesions in this series 
were associated with internal mammary nodal metastasis. If such be true, 



Medical News Letter, Vol. 3Z, No. 6 15 



then parasternal recurrences may be due to direct extension or retrograde 
permeation from involved lymph nodes in this important region. Fifty-three 
percent of the parasternal recurrences were associated with lack of evident 
metastasis to axillary nodes. This suggests the possibility that mediastinal 
metastasis occurred at the same time as, or prior to, metastasis to the 
axillary nodes. 

Recurrence along the margin of the scar would seem to suggest that 
not enough skin had been removed. The percentage of patients living 5 years 
or more and the reported incidence of local recurrence are unaffected by the 
type of operation. Most surgeons consider primary closure preferable to 
skin grafting, especially as it does the patient no harm. All incisions in this 
series were closed by the plastic technique. The incidence of local recurrence 
within or adjacent to the scar was not unduly high (Z0%). Conway and Neumann, 
using the Halsted-Thiersch graft procedure, found that 67. 5% of their local 
recurrences were in the immediate vicinity of their skin grafts, 15% were 
within the graft, and 17. 5% took the form of innumerable foci widely scattered 
over the thoracic wall. They concluded that it probably never will be possible 
to avoid local recurrence as is evident by the fact that 32. 5% of the recurrences 
appeared within the grafted area or as widespread foci. 

The present study and those of others indicate that survival after clinical 
recurrence is usually poor and bears no relation to the length of the cancer- 
free period before recurrence. A factor of individual host resistance seems 
probable; decompensation of host resistance is followed by accelerated growth 
of the neoplasin, metastasis, and death. (Pawlias, K. T. , Dockerty, M. B. , 
Ellis, F. H. , Jr., Late Local Recurrent Carcinoma of the Breast: Ann. Surg., 
148 : 192-196, August 1958) 

****** 

Health and Safety in Tran sportation 

The assurance of health and safety in transportation has become one 
of the basic needs in modern life. In certain areas of the world, safety in 
transit is assuming even greater importance than problems relating to food, 
shelter, and clothing. In the United States, for example, extensive mech- 
anization of the environment, diverse industrial procedures, and increasing 
use of transport vehicles have resulted in new threats to the well-being of 
large sections of the population. 

Current approaches to the control of accidents may possibly be reach- 
ing the limits of their effectiveness. The next significant advances in safety 
may result from a combined approach which includes the engineering and 
biological sciences. This collaboration is not new in medicine and such an 
approach has been the basis of many important developments. In 1956, buses, 
autonfiobiles, taxis, and trucks, operated by 77 million licensed drivers. 



16 Medical News Letter, Vol. 32, No. 6 



traveled some 630 billion miles on the highways in the United States. 
Drivers and passengers in automobiles and taxis alone accounted for 970 
billion passenger-miles of travel; 51-1/2 billion passenger-miles were re- 
corded in intercity bus operations. 

In aviation, the volume and speed of travel have been increasing very 
rapidly. During the first 24 years of the air transportation industry, that 
is up to 1950, 100 million revenue passengers were carried by scheduled 
domestic and international carriers in the United States. By 1957, 349 
million revenue passengers had been carried. The number of revenue pas- 
sengers on airlines of the United States in 1956 was about 46 million. These 
represented about 70% of the total world volume of 68 million revenue pas- 
sengers on airlines. In 1956, for the first time more passengers were 
carried to Europe by air than by ocean liner, and 68% of all passenger traffic 
between the United States and other nations was by air. Helicopter scheduled 
airlines were nonexistent 5 years ago. In 1957, this new type of service 
carried 152, 000 passengers. 

The frequency of accidents now presents a nriajor problem. Each year 
approximately 95, 000 persons are killed in various kinds of accidents in the 
United States. About 350,000 others receive permanently disabling injuries, 
temporary disabilities severe enough to keep them away from work for at 
least a day are incurred by 9-1/2 million persons. These accidents occur 
mainly in the home, on the job, and during transit. Accidents in various 
forms of transportation, particularly on the highway, have reached epidem- 
ic proportions. Since the invention of the automobile there have been more 
than a nnillion fatalities in motor vehicle accidents in the United States; 
in 1957, highway accidents accounted for 41% of all accidental deaths. The 
annual direct costs of traffic accidents approximate 2% of the national in- 
come. Fatal accidents involving persons under 35 years of age formed a 
large proportion of the total deaths in highway accidents. 

In the armed services, accidental trauma is now a major problem. 
During World iVar II, the U.S. Army reported more deaths among its soldiers 
caused by accidents than by disease for the first time in its history. In the 
Korean conflict, more than half of the hospitalized casualties resulted from 
accidents rather than from enemy action. Of these, 70% were incurred in 
motor vehicle accidents. The frequency of motor vehicle accidents in all 
three branches of the Armed Forces has become very serious, and accidents 
now exceed upper respiratory infections and rank first as the leading cause 
of man-days lost. Motor vehicle accidents account for about 2100 fatalities 
of servicemen each year, a large majority occurring while personnel are 
off duty. 

The integi\ation of motor vehicles into our way of life has become very 
costly in fatalities, injuries, and damaged equipment. In spite of the enor- 
mous increase in volume of highway traffic, there has been a significant 
decrease in accident rates during the past 25 years. In 1957, the fatality 
rate per 100 million miles of travel was only 5, 9 in comparison with the rate 



Medical News Letter, Vol. 32, No. 6 17 



of approximately 15 about ZO years ago. Nevertheless, the actual number 
of persons killed or disabled and resulting costs to the Nation's econonriy 
have increased from year to year with only a few exceptions apart from the 
period of restricted travel during World War II. In 1957, there were approx- 
imately 38, 500 deaths and 1, 350, 000 injuries disabling beyond the day of the 
accident. According to present trends, it is estimated that 1 of every 10 
persons in the country will be injured or killed in a traffic accident during 
the next 15 years. 

The safety record of scheduled airlines in the United States is an 
enviable one in relation to the exposure. Only 154 fatalities were reported 
for 1956, with the 128 deaths in the Grand Canyon accident accounting for 
approximately five -sixths of the total. In 1957, there were 31 deaths. 
Business flying is reasonably safe, but private flying has a relatively poor 
record. There were 655 fatalities in 1956 in 3411 accidents among 65,000 
business and private planes. Thus, 1 in about every 19 of these airplanes 
was involved in an accident. Crop dusting by airplanes — of great importance 
to both public health and agriculture — is also hazardous. Military flying 
obviously involves increased hazards. However, in United States naval 
aviation, there is now only about one fatality per day. 

Results of a number of studies clearly indicate that in relation to 
their numbers drivers up to the age of about 25 have accidents more fre- 
quently than do those from 30 through 60 or 65 years of age. The most 
recent and complete information, froin Massachusetts and Connecticut, 
indicates the highest rates for the youngest drivers, those of age 16. The 
rate decreases with succeeding years of age, rapidly at first and then nnore 
slowly. It levels off at about age 30 and rennains stable and relatively low 
through age 65. Data related to ages above 65 are as yet too meager for 
interpretation. The factors responsible for the higher rates for youthful 
drivers are believed related to inexperience and to psychological character- 
istics of youth in the adolescent and early adult phases of adjustment. 

Of the greatest importance in driving safety are the attitudes and per- 
sonal adjustments of drivers. A useful concept which has been developed 
in this area is that "a man drives as he lives. " Studies of accident repeat- 
ers and accident-free drivers carried out in Canada showed that nnaladjust- 
ments in meeting the personal and social demands of living were far more 
frequent among the accident repeaters than annong accident-free groups. 

A large sample of truck drivers was evaluated in a study at Harvard 
University. Accident-repeater and accident-free drivers were carefully 
matched to mieet rigid standards and various public records were searched 
for their names. Findings very similar to those in the Canadian study were 
obtained. 

In another study, infornnation from the service records of 210 military 
pilots who had been killed in noncombat aircraft accidents was connpared with 
records of a 20% sample of reserve pilots discharged after satisfactory service 



18 Medical News Letter, Vol. 32, No. 6 



(personal communication). A record of disciplinary charges was found for 
48% of the fatal accident group as against 31% of the control group. "Vio- 
lation of flying orders" was the most discriminative type of offense — 21% 
of the fatal accident group as against only 2% of the controls. Nonflying 
disciplinary infractions were also significantly different in the two groups, 
the accident group rating higher in resistance to order and discipline. 

In situations involving time stress and complex reactions, the lower 
accident rate for adult and middle-aged drivers is clear, but for persons 
past middle age there is some evidence that the rate may increase. It is 
known that reaction times tend to become longer with advancing age, and 
impairment in the efficiency of all senses occurs. Many persons, however, 
develop compensating habits offsetting these losses. It is believed that older 
drivers tend to drive slower and to do less driving at night. 

Many accidents occur when the efficiency of the driver is impaired 
by some temporary condition. The efficiency and safety of driving may be 
adversely influenced by a variety of temporary states, although in general, 
statistical proof of the importance of a given type of condition may be very 
difficult to obtain. The role of fatigue in asleep-at-the -wheel accidents 
appears quite clear, but fatigue nnay be a more subtle factor in many other 
accidents. 

Driver fatigue is not only related to the length of time spent in driving. 
Consideration must also be given to such factors as amount and quality of 
previous rest, the nature of activities prior to driving, and concurrent 
emotional stress. In addition to the subtle disorganization of skill which 
develops with increasing fatigue, drivers when extremely tired may exper- 
ience hallucinations of obstacles on the highway; a number of accidents have 
been traced to actions taken by drivers to avoid collision with these imagined 
barriers. 

Driving skill is adversely influenced in many with as little alcohol in 
the blood as 0, 03 and 0. 04%. The likelihood of an accident increases con- 
stantly as the alcohol in the blood increases from the lowest levels. The risk 
at 0, 10% is estimated to be nnore than twice that at 0, 05%, while the risk at 
0, 15% appears about tenfold. In several series of autopsies recently made 
on drivers killed in accidents in the United States, significant amounts of 
alcohol were found in the blood and brain fluids of more than half of the cases. 

Most authorities would agree that epileptics, diabetics requiring insulin, 
and those with certain heart conditions should not operate public highway con- 
veyances or pilot airliners because of the hazard of a sudden loss of conscious- 
ness. But what of the influence of such conditions in the general driving pub- 
lic and what cutoff points should be kept in mind? There are, for example, 
about 6 million truck drivers in the United States, yet it is known that only 
a small proportion of them receive thorough physical examinations and that 
the development of adequate medical programs for the large number of work- 
ers in the transport industry remains to be accomplished. It would be expected 



Medical News Letter, Vol. 32, No, 6 19 



that in this occupational group a certain number use insulin, experience 
temporary impairments of consciousness, or have fairly advanced heart 
disease of one form or another. 

The need for research to evaluate the influence of specific conditions 
in traffic accidents and to establish critical cutoff points is very great; 
physicians obviously can make important contributions in this regard. The 
limitation on driving for persons with various illnesses or disabilities 
presents a serious problem. An arbitrary prohibition of driving for all 
those afflicted with certain conditions would be needlessly restrictive and 
unfair to many persons, and cooperation between the medical profession and 
the motor vehicle authorities in handling these problems on an individual 
basis is essential. 

In the field of air transportation, airline pilots receive periodic phys- 
ical examinations through designated medical examiners of the Civil Aero- 
nautics Administration. A few of the 80 airlines of the world have good 
medical departments, but less than one -fifth of the scheduled airlines have 
formal medical organizations. The report that each month for a 5-month 
period in 1957, a pilot on active duty died while in the cockpit will empha- 
size the importance of continuing medical supervision as well as of the value 
of having a co-pilot. Gne of the pressing problems in this area relates to 
the changing age distribution of airline pilots. With many of these men now 
entering age groups beyond 45 and 50, many problems of health and safety 
inay be anticipated. 

Many factors in the environment may influence the efficiency and 
safety of the operators of vehicles. Illumination, bad weather, and toxic 
agents, such as carbon monoxide, are important in highway safety, while 
temperature and humidity, and ventilation are significant under extreme 
conditions. Noise and vibration are known to be excessive in certain types 
of highway vehicles. In aviation, the development of the pressurized cabin 
is of special interest because it affords an unusual illustration of the rela- 
tionships between the host, the agent, and environmental factors affecting 
both health and safety. 

A significant factor in host-environment relationships is efficiency 
of vision. In the United States, accident rates per unit of travel are 
three times higher at night than during the day. Presumably, this is 
due partly to the lowered visilibity provided by night-time illumination, 
a contention supported by lower accident rates on lighted highways and 
by the reduction in rates following improvement of illumination on par- 
ticular highways. 

It has been calculated that for a dim light or object to be seen by an 
eye in the dark^ the illumination must be doubled for every increase of 13 
years of age. The use of tinted windshields by older drivers may present 
special hazards at night because the glass further reduces visibility by 
reducing the intensity of light reaching the eye. 



ZO Medical News Letter, Vol. 32, No. 6 



The accepted function of medicine has been the treatment of disease 
and injury. Just as the province of medicine has been extended to include 
the prevention of disease, it is proposed that the prevention of accidental 
trauma should be a responsibility of preventive medicine and public health. 

tVhen accidental trauma is considered a noncontagious mass disease 
of epidemic proportions, the epidemiological approach should be applied 
to the study and control of injuries because similar biological principles 
are involved. An interdisciplinary approach is a basic requirement in this 
because multiple causation is found in most accidents. 

The causes of accidents may be identified in the interactions between 
the host, the agent (or equipment), and variables of the environmient. Human 
factors are especially important and the physician can contribute effectively 
in the analysis of accident causes because of his background in the biological 
sciences and his knowledge of human behavior. He can indoctrinate his pat- 
ients and teach while treating. 

Factors of significance to the host in the control of accidental trauma 
include not only those which determine suitability for a given task, such as 
driving a vehicle or piloting a plane, but also such factors as age, training, 
and particularly, personal adjustments. 

The control of various temporary host factors, such as fatigue, errto- 
tional problems, effects of alcohol, and the influence of disease is highly 
important. Periodic medical examinations and adequate progranns of health 
maintenance can play a significant role in improving safety both in land and 
air transportation. 

Biotechnology and human engineering should be applied to the design 
of equipment in order to achieve a closer integration between the operator 
and his equipnnent. 

The agent of disease also is significant in modern transportation 
because insect vectors of disease might be transported in planes and other 
vehicles and because long journeys may now be completed within the incuba- 
tion period of contagious diseases. 

Host-environment relationships also have implications for safety in 
transportation because of the influence upon the individual of physical var- 
iables, such as the level of illumination, temperature and humidity, and 
exposure to carbon monoxide and other toxic agents. Data have been 
worked out for each of these variables outlining the zones of comfort and 
discomfort and the ranges where huraian performance is adversely influenced. 

In air transportation, the low tension of oxygen at high altitudes and 
decrease in baronrietric pressure with altitude are significant not only for 
their influence on the performance of airmen, but also because of their impli- 
cations for the safety of travel by air by persons who are physically unfit or 
who are afflicted with certain diseases or physical conditions. These same 
factors are of critical importance in the development of equipment to trans- 
port passengers at very high altitudes because of their significance in the 
case of a sudden loss of pressurization. 



Medical News Letter, Vol. 32, No. 6 21 



The physician or the public health officer has a direct responsibility 
for the prevention of accidental trauma. He may contribute most effectively 
by his aid in carrying out controlled experimental and clinical studies, epi- 
demiological surveys, and by collaborating with specialists in other bio- 
logical sciences, with engineers, and administrative officers in a combined 
approach to this problem. {McFarland, R.A. , Ph.D. , Health and Safety in 
Transportation: Pub. Health Rep. , 73: 663-679, August 1958) 

jfc ?{f sfe life rfc jjc 

Changes in Threshold Limit Values 

The threshold limit values contained in BuMed Instruction 6260. 5, 
Change 2, were taken from values adopted at the 19th Annual Meeting of the 
American Conference of Governmental Industrial Hygienists in April 1957. 

During the 20th Annual Meeting of this Conference, 19 - 22 April 
1958, the following changes to the 1957 list were made: 

1. HETP (Hexaethyl tetraphosphate) was removed from the list. 

2. The value for mesityl oxide was reduced from 50 p.p. m. to 25 p. p. m. 

3. New substances added Parts per nrjillion Milligrams per 

cubic meter 

Phosphoric acid 1 

Trichloropropane 50 300 

sec -Hexyl acetate 100 590 

Triorthocresyl phosphate 0. 1 

n-Propyl nitrate 25 110 

Epichlorohydrin 25 90 

1-1 dimethylhydrazine 0.5 1 

Chlorine dioxide 0.1 

These changes will be reflected in Change 3 to BuMed Instruction 
6260. 5, Threshold Limit Values for Toxic Materials, which will be protnul- 
gated in about two months. (OccHealthEngBranch, OccMedDispDiv, BuMed) 

!^ S{C 9{C ^ iS^E 9JC 

Industrial Medicine 

Industrial health is a specialized combination of medical and public 
health practices, uniting all relevant disciplines with the dual object of 
improving the worker's physical and inental efficiency and increasing pro- 
duction. 



22 Medical News Letter, Vol. 32, No. 6 



1 



As industry has come to realize the value of keeping workers healthy, 
industrial medical programs have expanded rapidly. The physical examina- 
tion is the keystone of the preventive medical program. The earliest pre- 
employment examinations were intended primarily to discover existing 
physical defects so that they might not be alleged to have occurred in the 
course of employment. These are now known as preplacement examinations. 
They are designed to insure the assignment of workers to jobs that are com- 
mensurate with their physical and mental capacities. Periodic and transfer 
examinations are also regular parts of the health maintenance program. 
Special examinations are made on individuals exposed to known hazards or 
to those persons whose Jobs involve the safety of other workers. 

The objectives of occupational health are achieved through the coop- 
eration of industrial medicine, industrial hygiene, safety, and engineering. 
Unlike other specialties, the industrial medicine specialty is a broad one. 
The industrial physician needs a working knowledge of chemistry, engineer- 
ing, psychology, and business administration. A proper placenrient exam- 
ination cannot be made unless he is familiar with the job, its physical de- 
mands, and its inherent hazards as well as the physical capacities and 
limitations of the employees. 

Work carried on in industrial toxicology laboratories adds to the know- 
ledge of the action of diseases on the human body. Basic research provides 
newer information on the subtler functional changes and a basis for earlier 
and more reliable diagnostic procedures. Techniques developed to study 
the mechanism by which a substance exerts its deleterious biologic action 
often can be utilized in the study of other diseases. 

As more and more new compounds flow from the research and devel- 
opment laboratories to the production line, the need for toxicologic research 
grows correspondingly more urgent. Not only is it necessary for the indus- 
trial physician to know the effects that toxic substances may have on workers 
but the welfare of the consumers must be considered as well. Where harm- 
ful properties are inherent in a product, it is the responsibility of the man- 
ufacturer to set up codes for its safe handling and use by the public. 

Industrial medicine encompasses all medical and public practices and 
depends upon cooperation between the industrial physician and the private 
practitioner to achieve its primary objective — the maintenance of a healthy 
efficient work force. This objective is accomplished through physical eval- 
uation, health maintenance, medical and surgical care, industrial hygiene, 
and research. (Walmer, C. K. , Industrial Medicine - The Newest Specialty: 
Penna. Med, J., 62:748-751, Jime 1958) (OccMedDispDiv, BuMed) 

}JC <^ ^ i^ ^ 3JC 



Medical News Letter, Vol. 32, No. 6 23 

Letters from General Pate and General Hays 

"27 August 1958 

My dear Admiral Hogan: 

It is my privilege to extend heartiest congratulations 
and best wishes from the United States Marine Corps to you 
and to the other members of the Navy Medical Corps upon 
the occasion of the ll6th anniversary of the founding of your 
splendid organization. 

The record of the Navy Medical Corps throughout the 
years is a most distinguished one, and an inspiration to all 
Americans. It is a record of high personal courage, dedicated 
service to humanity, unselfish devotion to duty, and outstanding 
professional competence. We Marines cherish the strong bonds 
of friendship which have developed through the years between the 
Navy Medical Corps and our own Corps. 

With warmest personal regards and every good wish for 
the continued success of your Corps for many more anniversaries 
to come, I remain 

Sincerely yours, 

R. McC. PATE 
General, U. S. Marine Corps 
Commandant of the Marine Corps 



Rear Admiral Bartholomew W. Hogan, (MC) USN 
Chief, Bureau of Medicine and Surgery 
Department of the Navy 
Washington 25, D. C. " 



24 Medical News Letter, Vol. 32, No. 6 



"Eear Admiral B. W. Hogan, USN 
Surgeon General 
Department of the Navy 
Washington 25, D. C. 

Dear Admiral Hogan: 

The entire Army Medical Service joins me in extending 
congratulations to each member of the Bureau of Medicine and 
Surgery as you celebrate your 11 6th anniversary on 31 August. 

We in the Army Medical Service are fortunate in being 
associated with an organization which has so distinguished itself, 
and we look forward with pleasure to continued cooperation with 
the Bureau of Medicine and Surgery. 

My sincere best wishes for your continued success. 

Sincerely, -v 

/s/ 

S. B. HAYS 

Major General 

The Surgeon General" 

^ ^ 3fC ^ 3^ SfC 

Fronn the Note Book 

1. Rear Admiral JR. vV. Malone DC USN, Assistant Chief for Dentistry, 
and Chief, Dental Division, Bureau of Medicine and Surgery attended the 
Forty-Sixth Annual Meeting of the International Dental Federation held in 
Brussels, Belgium, August 27 to September 2, 1958. (TIO, BuMed) 

2. Captain J.J, Engelfried MSC USN represented the Navy Medical Depart- 
ment and the Department of Defense at the Seventh Congress, International 
Society of Blood Transfusion held in Rome, Italy, September 3-6, 1958. 

(TIO, BuMed) 

3. CDR Margaret S. Lincicome MSC USN, Instructor of Parasitology, Med- 
ical Research Institute, National Naval Medical Center, participated in the 
Sixth International Congress on Tropical Medicine and Malaria held in 
Lisbon, Portugal, September 5-8, 1958. (TIO, BuMed) 




Medical News Letter, Vol. 32, No. 6 25 



4. Captains W.W. Ayres MC USN, V. G. Colvin MC USN, and T. M. Foley 
MC USN were placed on the retired list of Naval officers on 1 September 1958. 

(TIO. BuMed) 

5. This study discusses the value of angiocardiography as an aid in the 
early diagnosis and prognosis of bronchogenic carcinonia. This technique 
is of particular value for the peripheral lesion where other findings may 
be inconclusive. (Am. J. Med. Sci. , August 1958; H.A. Lyons, M. D. , 
F. Vertova, M. D. ) 

6. In a review of 238 cases of gastrojejunal ulcer the diagnostic problems 
of the radiologist are stressed. Suggestions are made concerning radio- 
logical technique and the common and important diagnostic problems are 
discussed. (Radiology, August 1958; K. Ellis, M. D. ) 

7. This article reports 9 cases of tuberculous lymphadenitis treated with 
trypsin in sesame oil and uninterrupted antituberculous drugs. Follow-up 
periods varied from 8 to 16 months, including histopathological evaluation 
of the results of treatment. (Dis. Chest, August 1958; C. Rapoport, M. D. , 
Israel) 

8. Clinical and hematologic findings are presented in 18 cases of agranulo- 
cytosis which followed treatment with chlorpromazine. Granulocytopenia 
was of gradual onset and followed prolonged treatment with large cumulative 
doses of chlorpromazine. (Am. J. Med., August 1958; A. V. Pisciotta, M. D. 
et al. ) 

9. This study presents observations on the antigenic potency of poliomyelitis 
vaccine (Salk type) as mieasured by serologic tests on serum of vaccinated 
children and on the safety of vaccine used for this study. (J. Dis. Chil. , 
August 1958; K. Sunada, M. D. , et al. ) 

10. This article describes an improved device which has been used success- 
fully for the prevention of injuries in the region of the face and head in con- 
tact sports. (Dental Digest, August 1958; J. F. Cathcart, D. D. S. ) 

11. The diagnostic value of biopsy of nonpalpable scalene lymph nodes in chest 
diseases is discussed. (Ann. Surg., August 1958; T. W. Shields, M. D. , 

W. M. Lees, M. D. , R. T. Fox, M. D. ) 

12. The proper selection of cases for heart surgery is discussed. (Postgrad, 
Med., August 1958; H. Swan, S. G. Blount, Jr.) 

:{<: 3|c ^ j^ 3^ 9jt 



26 Medical News Letter, Vol. 32, No. 6 

Voluntary Retirement 

Retirement after 20 or nnore years of service has been authorized 
since 1955, and a number of Medical Department officers have been granted 
this early retirement. It is felt that the availability of early retirement is 
a distinct addition to the attractiveness of a Navy career. 

While general information on voluntary retirement appears to be 
widely distributed, letters and comments received indicate that some of 
the details are less widely known. The specific criteria prescribed by the 
Secretary of the Navy as meriting favorable consideration for early retire- 
ment are stated in SecNav Instruction 1811. 3A of 10 September 1955, and 
anyone thinking of making such a request should be fully acquainted with 
this instruction as well as BuPers Instruction 1811, lA of 19 July 1957. 

Among the six criteria listed is that of five years' service in grade 
for captains as well as 20 years' total service. Other of the listed criteria 
may be applicable to individual cases. Requests are considered on a basis 
of the over all needs of the Service and the nnerits of the individual case. 

Requests should be submitted at least three nionths and not more than 
six months ahead of the desired date, and the preretirement physical must 
be reported to the Chief of Naval Personnel from one to three months in 
advance. BuPers requires that officers starting a new tour of duty complete 
at least one year at the new station before voluntary retiremient is effected. 

Obviously, an unexpected request for retirement creates problenns 
in connection with a relief, and in some instances insufficient time has been 
allowed in which to arrange for a relief. Consequently, it is most desirable 
that BuMed be informed of prospective retirennent plans as far as possible 
in advance of the prescribed three months lead time to insure that the de- 
sired retirement date can be miet. 

The Bureau is in no sense urging officers to consider early retire- 
ment. This note is simply to urge those who nnay be thinking of early 
retirement to become familiar with the requirements and proper procedure 
as detailed in SecNav and BuPers Instructions, (PersDiv, BuMed) 

:{(>{( ^ »[£ >}c 4: 

Board Certifications 



American Board of Internal Medicine 
LT Robert E. DeForest MC USN 
LCDR Max E. Musgrave MC USN 
CAPT James L. Spencer MC USN 

American Board of Neurological Surgery 
LCDR Ernest J. Penka MC USN 



Medical News Letter, Vol. 32, No. 6 27 



American Board of Obstetrics and Gynecology 
LCDB Robert C. Drips MC USN 
CDR Halvdan G. K. Fas land MC USN 
LT Mable A. Frew MC USN 

American Board of Preventive Medicine (Occupational Medicine ) 
CAPT David H. Hersh MC USN 

American Board of Ophthalmology 

LT Harold D. Esterly, Jr. MC USN 
CDR James I. Thorn MC USN 

American Board of Pathology 

LT G. E. Aponte MC USNR (Active) 
CAPT vVilliam W. Ayres MC USN 
LT William E. Cowell MC USN 
CDR Robert M. Dimmette MC USN 
CDR David B. Rulon MC USN 

American Board of Radiology 

LT Paul W. Mathews, Jr. MC USNR (Active) 
LT »Villiam R. Nicolay MC USNR (Active) 
LT Matthew F. J. Yenney, Jr. MC USN 

American Board of Surgery 

LT Claude H. Organ MC USNR (Active) 

* * * :j( * !jc 

Recent Research Reports 
Naval Medical Research Institute, NNMC, Bethesdaj Md . 

1. Effect of Total-Body X-Radiation from Near Threshold to Tissue-Lethal ' 
Doses on the Small Bowel Epithelium of the Rat. I. Changes in Morphology 
and Rate of Cell Division in Relation to Tiine and Dose. NM 62 02 00. 02. 01, 
23 January 1958. II. Changes in Nucleic Acid and Protein Synthesis in 
Relation to Cell Division. NM 62 02 00. 02. 02, 24 January 1958. 

2. Prevention of Heat Casualties. NM 41 01 00. 01. 01, 21 March 1958. 

3. Studies on Experimental Shigellosis. II. The Effect of Fasting and Fatigue 
on S. Flexneri 3 Infections in Mice. NM 52 04 00, 01. 03, 21 March 1958. 

4. An In Vivo Change of Serological Specificity in Shigella Flexneri 3. 
NM 52 04 00 . 01. 04, 21 March 1958. 



28 Medical News Letter, Vol. 3Z, No. 6 



5. Ethylene Oxide Sterilized Freeze-Dried Dura Mater for the Repair of 
Pachymeningeal Defects, 70 01 00.01.01, 3 April 1958. 

6. The Acetylcholinesterase Surface. IK. Dependence of Competitive 
Inhibition by Diaminocyclohexane Derivatives on Substrate Level. NM 02 02 00 
. 01. 06, 14 April 1958. 

7. Susceptibility and Resistance of Avian and Mosquito Hosts to Strains of 
Plasmodium Relictum Isolated fronn Pigeons. NM 52 01 00. 02. 01, 15 April 
1958. 

8. Serologic Reactions in Schistosoma Mansoni Infections. IV. Comparative 
lonographic Study of Sera of Hamsters, Mice, and Albino Rats. NM 52 02 00 
.01.02, 18 April 1958. 

9. Effect of Carbohydrate Refining on Body vV eight and Dental Caries in the 
Rat. NM 75 01 00. 03. 01, 25 April 1958. 

10. The Roles of Endocrine and Behavioral Factors in the Growth of Mammal- 
ian Populations. Lecture and Review Series, No. 58-1, 22 May 1958. 

Naval Air Development Center, Johnsville, Pa. 

1. Effect of Simulated Catapult Launching on Pilot Performance. Report No. 1, 
NM 11 02 12.2, 31 December 1957. 

2. Behavioral Effects of Whole Body Vibration, Report No. 1, NM 18 01 12.4, 
28 January 1958. 

3. Air-to -Air Tracking during Closed-Loop Centrifuge Operation. Report No. 1, 
NM 18 01 12. 1, 10 March 1958. 

4. Effect of Hypoxia on Tolerance to Positive Acceleration. Report No. 1, 
NM 11 02 12. 3, 12 March 1958. 

5. Erythrocyte Hydration \inder Positive Acceleration. Report No. 1, 
NM 19 02 12. 1, 7 April 1958. 

6. Variation in Duration of Oculogyral Illusions as a Function of the Radius 
of Turn. Report No. 2, NM 18 01 12.2, 22 May 1958. 

7. Effects of Positive Acceleration upon the Performance of an Air-to-Air 
Tracking Task. Report No. 2, NM 18 01 12. 1, 2 June 1958. 

8. The Relationship between Pain and Tissue Damage due to Thermal Radia- 
tion. Report No. 15, NM 19 01 12.1, 11 June 1958. 

Naval School of Aviation Medicine, NASj Pensacola, Fla. 

1. The Sentence -Completion Test as a Measure of Morale. Report No, 4, 
SubtaskNo. 4, NM 16 01 11, 12 March 1958. 

2. Note on Relation of Age to Attrition. Report No. 25, Subtask No. 1, 
NM 14 02 11, 15 April 1958. 

3. Evaluation of Certain Visual and Related Tests: I. Auditory and Visual 
Span. Report No. 1, SubtaskNo. 6, NM 14 01 11, 18 April 1958. 



Medical News Letter, Vol. 32, No. 6 



29 



DENTAL 




SECTIOIM 



Facilities and Materiel Programs 

Projects for new construction, expansion, or major alterations of 
dental facilities were completed at thirty -one shore based activities during 
Fiscal Year 1958. The majority of these projects provided for an increase 
in the total number of dental operating rooms available which will result in 
increased operating efficiency. Dental prosthetic laboratories were author- 
ized at fourteen activities bringing the total of authorized prosthetic facilities 
to one hundred and sixty -five. Four dental activities with prosthetic facili- 
ties were decommissioned during the year. 

^ ^ ^ ?S^ ^4: aSf 

High-Speed Dental Radiographic Film 

Attention is invited to a higher speed dental radiographic film which 
was recently added to the Armed Services Medical Stock List. The film's 
high speed emulsion permits reduction of exposures from one-third to one- 
quarter the time required for intermediate speed film and, therefore, nnin- 
imizes the radiation hazard to patients and operating personnel. The life 
of x-ray tube heads is also prolonged. Nomenclature for procurement is: 

FSN 6525-663-1558 - Film, Dental Radiographic, 1-1 /4 inches, 150's: 

Single film packets, dispenser type package. 
Speed group 2. 0; suitable for use in long cone 
techniques. 
This item supplements FSN 6525-601-5010, Film, Dental Radiographic, 
1-1/4 by 1-5/8 inches, 144's. It is suggested that the high speed dental radio- 
graphic film be used in lieu of the intermediate speed film to the fullest ex- 
tent possible. 

iff iff ://: :^ i^ ^ 

Induction and Separation Exanninations 



Instruction 6120. 4A provides current instructions regarding induction 
dental examinations as described in Article 6-52, Manual of the Medical 
Department, and modifies procedures for separation dental examinations. 



30 Medical News Letter, Vol. 32, No. 6 




RESERVE SECTION 



New Component in Selected Reserve Forces 

A new component has been established within the Selected Reserve 
Forces of the Naval Reserve — the Active Fleet Augmentation Component 
(Surface and Submarine). 

The component is made up of all currently authorized Surface, Sub- 
marine, Electronics, and Fleet Divisions and their supporting battalion and 
brigade staffs. It will also include Training Divisions when established. 

Reservists in this component will be trained to fill billets in active 
Fleet ships. As currently practiced, rate training, supplemented by team 
training and active duty for training (AcDuTra), will fulfill training require- 
ments. Thus, there will be no drastic changes in the training program. 

Personnel assigned to the new component will be those needed immed- 
iately at the outbreak of hostilities involving the United States. Reservists 
taking part in the program will constitute, in effect, an existing component 
of the wartime active Fleet because they will be preprocessed, preordered, 
and immediately available for combat duty. Because of their degree of readi- 
ness, it will not be necessary to order them to active duty until there is a 
specific need. They will not be ordered to active duty for such purposes as 
manning the Reserve Fleet or augmentation of the shore establishment in the 
event of partial mobilization. 

Reservists in attached and associate status will be issued precut mob- 
ilization orders to report to their training centers for routing to their ultimate 
duty stations in the Fleet or as may be directed by the district commandants. 

Those in associate pay status will be issued mobilization assignments 
in accordance with their individual qualifications. Those who are fully qual- 
ified will be assigned to the Fleet as part of the Active Fleet Augmentation 
Component (Surface and Submarine). Others who are qualified for active duty, 
but who do not meet all requirements for assignment to the Fleet, may be 
utilized initially to augment support personnel at training centers until mob- 
ilization processes have been completed. Once this phase is completed, 
these Reservists will be assigned to other billets. 

The basic organization of the programs included in the new component 
will remain unchanged and there will be no phased transition period. 

(The Naval Reservist, July 1958) 

5^ 3^ ^ 3^ ^ ^ 



Medical News Letter, Vol. 32, No. 6 31 



Informative Publications 



Any inactive Medical Department Reservist may obtain gratis a copy 
of the follo\wing informative pamphlets upon request to his District Comman- 
dant (District Medical Officer). 

Navy Reserve Medical Department Program^ . Developed by the Reserve 
Division, Bureau of Medicine and Surgery, this printed booklet provides de- 
tailed infornnation concerning the Naval Reserve Medical Department Program. 
It covers such subjects as training, pay, promotion, retirement, opportunities 
for undergraduate and graduate medical students, terminology, and pertinent 
references of the Naval Reserve, available free publications, and questions 
and answers concerning the individual's participation in the Naval Reserve. 
This pannphlet is a handy reference containing useful and valuable information 
for motivated MD Reservists. 

Creditable Correspondence Courses for Inactive Reserve Medical De- 
partment Officers. This pamphlet lists creditable correspondence courses in 
three nnain areas of study: executive, operational, and technical with appro- 
priate general and professional correspondence courses available to eligible 
inactive Reserve MD officers of all ranks. Also furnished are promotion 
point requirements and instructions for making application for enrollment in 
a particular course. This pamphlet is a must for the Reservist endeavoring 
to qualify for promotion to the next higher rank. 

^ ;^ ^ »|( 9>c :{: 



-vve-* 




Wf. 



PREVEIMTIVE MEDICIIVE SECTIOIM 



Influenza 

The appearance of another antigenic variant of Type A influenza (Asian 
or Far East) in a relatively nonimmune world population in the spring of 
1957 was followed by the expected widespread dissemination of the virus. 
Despite immediate recognition of the initial outbreaks of illness with isola- 
tion and identification of the offending agent, the tools were not at hand to 
prevent the disease from reaching pandemic proportions. Fortunately, the 
mildness and brevity of the disease and the infrequency of associated deaths 



32 Medical News Letter, Vol. 32, No. 6 



remained fairly constant as the initial wave swept from country to country. 
Exceptions in isolated circumstances were probably due to factors other than 
change in the virus. Even though increasing virulence of the virus, sever- 
ity of the disease, or frequency of complications were not the problems, an 
illness affecting millions of persons throughout the world deserves critical 
examination with all facilities available. The experience of the past year 
amply demonstrated the inability of vaccine to restrict the spread of a new 
antigenic variant of influenza even in those countries prepared for rapid 
vaccine production. Barring the development of universal influenza A and 
B antigens, new methods for control, or therapy of viral infections, it be- 
comes obvious that more information is needed on the immediate as well as 
the long-term effects of influenza, proper therapeutic measures, and the 
prevention of complications. 

A better understanding of the mechanism of clinical features certainly 
is required, ^^'hether initial infection occurs in the nasopharyngeal mucosa 
in nnan is not known, although symptoms are sometimes referable to this 
area. Effects have been noted in the mucosal lining of the tracheobronchial 
tree from uncomplicated influenza as well as associated deaths, and have 
consisted of areas of denudation and metaplasia with submucosal edema. The 
next step in disease mechanism is not clear. Clinical njanife stations extend 
far beyond the respiratory tract and frequently are minimal in that area. 
Does the virus spread to other organs or is there a circulating toxin? The 
influenza virus particle itself has been shown to be toxic to laboratory ani- 
mals, but a soluble toxin has not been associated with active infection. 
Viremia has not been described in influenza in nnan, but this could be the 
result of insufficient effort in this direction or to its occurrence prior to 
onset of symptoms. Multiplication of this virus in other tissues seems less 
likely than poliomyelitis. The latter has been propagated in most human 
tissues in culture, but growth of influenza virus has been demonstrated only 
in lung and kidney culture. It would certainly be valuable to know whether 
viral multiplication takes place in the kidneys or other areas of the intact 
host. Although delirium is associated with severe cases and postinfectious 
encephalitis occurs, virus has not been recovered from the central nervous 
system of man. The potentiality exists, nevertheless, because certain 
strains can be adapted to growth in the mouse brain. Similar questions arise 
regarding susceptibility of pericardial epithelium or vascular endothelium. 

Reasons for variation in severity of the disease in persons in the same 
epidemic are not known. Measurable differences in virulence of strains 
isolated in an epidemic have not been found. Possibly, there is less viral 
multiplication or neutralization of tissue -damaging activity in some persons 
owing to antibody or nonspecific inhibitors or physical restriction of the 
disease to the initial site. The cause of the prolonged deep productive cough 
that sometimes continues after the acute phase of the illness has not been 
related to specific bacteria or preexisting pulmonary disease. Although this 



Medical News Letter, Vol. 32, No. 6 33 



could be the result of the degree of mucosal destruction, secondary bacterial 
infection amenable to therapeutic measures is a good possibility. The cause 
of the severe and prolonged asthenia following the acute phase of the illness 
is still unknown. If this were shown to be produced by an altered tissue or 
metabolite or deficit in a critical substance, the corrective measures might 
become obvious. 

Perhaps more pressing is the acquisition of insight into complications, 
such as pneumonia, severe toxicity with hypotension, myocarditis, or pre- 
cipitation of congestive heart failure. The fulminating nature of the bacterial 
pneumonia occasionally occurring in young adults or pregnant women and in 
persons in the extremes of life leaves little time for therapy and delay can 
result in a fatal outcome. Certainly, promiscuous prophylactic antibiotic 
administration is not the answer to this infrequent — although serious — prob- 
lem. Moreover, the peripheral leukocyte count is of doubtful aid because 
it is sometimes elevated in uncomplicated influenza and frequently depressed 
in most pneumonia cases with fatal outcome. Precision in diagnosis of the 
causative agents involved in pneumonia deaths would be useful in outlining 
management. So-called sterile lungs from patients given antibiotics prior 
to death are of doubtful meaning in assessing the role of bacteria or the 
virus. The difficulty in cultivation of certain bacteria, such as Hemophilus 
influenzae; the significance of antibiotic- sensitive organisms cultured from 
the lungs of patients treated with the same antibiotics; the presence of bac- 
teria in circumscribed areas and absence in others; the separation of con- 
taminants from the pathogens; and the lack of quantitative measure of bac- 
terial as well as viral infection are all problems in the way of elucidation of 
the etiology and mechanism of these pneumonias. 

Therapy of severe toxicity with hypotension and cyanosis in patients 
with uncomplicated influenza or bacterial pneumonia provides an additional 
dilemma. The administration of adrenal cortocoids might tide the patient 
through this phase; on the other hand, the incidence of bacterial pneumonia 
could be increased or the degree of tissue damage enhanced. Possibly, 
positive-pressure respiration would be of some value, but more pulmonary 
function studies are needed in patients with heart disease or pneumonia com- 
plicating influenza. How strictly should bed rest be enforced and for how 
many days in order to avoid sudden death — presumably due to postinfluenza 
myocarditis — is another important consideration. vVhat precautions should 
be taken by patients with heart disease, pregnancy, or other conditions prior 
to an epidemic or during their illness must be determined. These are all 
real problems that must be answered. In each instance, investigations of 
the disease mechanism are needed. Careful virologic and bacteriologic 
studies in conjunction with biopsy and autopsy material can be correlated 
with results of application of diagnostic and functional studies of all organs. 

It is rather surprising that the influenza viruses — especially during the 
Asian strain pandemic— have not produced more virulent variants. Only a few 



34 Medical News Letter, Vol. 32, No. 6 



intranasal passages in mice are required for adaptation; pneumonia and death 
will then occur after infection Evidently the factors are different in rnan- 
to-man transfer, for there are countless human passages of the virus during 
a worldwide epidemic. 

Many problems are still associated with influenza vaccines. They have 
been prepared in the allantoic sac of the ennbryonated egg and, consequently, 
cannot be administered to persons sensitive to egg protein. However, this is 
only a minor phase of the difficulties. The incidence of local and systemic 
reactions of a severe — although not dangerous — nature is considerable and 
can usually be correlated with the amount of virus in the vaccine. More in- 
formation is needed on multiple small injections or the suitability of adjuvants; 
the best route of administration and temporal spacing of inoculations must be 
determined. Other methods of preparation of the vaccine should also be in- 
vestigated. The techniques and production methods for poliomyelitis vaccine 
in monkey kidney cultures should be helpful in the preparation of influenza 
vaccine from such a system. Efficacy or protection are difficult questions 
to answer. Low levels of antibody might produce herd immunity that would 
suggest a high degree of protective effect by a given vaccine. This could be 
insufficient safety for the special risk patient with other conditions. Much 
information has been obtained on production of titratable antibodies after 
vaccination, but this is not the real test of the material. Methods of inacti- 
vation and purification also vary and may affect the immunogenicity of the 
virus, rfhat the role of circulating antibody might be in a disease affecting 
respiratory epithelium and, presumably, without a virennic phase is another 
matter for conjecture. Might the illness be restricted to an afebrile respi- 
ratory disease? //ould protection be complete? vi/ould viral multiplication 
take place in the absence of any symptoms, but still allow spread of the agent? 

Subsidence of the Asian influenza epidemic should not cause these prob- 
lems to be placed in the background. The facility of influenza viruses for 
antigenic variation will again set the stage for pandemic illness. Also, there 
are still many persons with little immunity against the Asian and the Denver 
strains of influenza A, and the degree of reciprocal immunity with these two 
viruses is probably low. Antibody levels to influenza B have now fallen to 
the point that outbreaks or epidemics can be expected. Even though the 
obvious influenza-associated deaths due to Asian virus were low in incidence, 
over all mortality rates were clearly elevated by this illness. In nonepidemic 
years, it is difficult to determine the effect of such respiratory virus infec- 
tions on death rates. Undoubtedly, the life expectancy of patients with chronic 
disease is frequently shortened by these illnesses and the results of many 
refinements in their nnanagement are accordingly nullified. 

Extension of the above problems and results of the investigations of 
thenn can be made to other respiratory virus infections in many instances. 
Influenza can serve as a useful tool in this respect. Many of the features of 
adenovirus illness are similar to influenza and it is likely that complications 



Medical News Letter, Vol. 32, No. 6 35 



could be handled in the same fashion. Undoubtedly, a multivalent respiratory 
disease vaccine would be a great asset not only in removing discomfort and 
economic loss, but possibly in reducing degenerative disease. A'hether 
complete recovery of bronchial mucosa occurs after infection, whether meta- 
plasia remains and predisposes to anaplasia later in life, and whether per- 
manent damage occurs in the cardiovascular or renal systems are all nnatters 
that should prevent physicians from being too philosophical about attacks of 
"the flu. " (Mogabgab, W. J. , Influenza: Arch. Int. Med., 101 ; 681-684. April 
1958) 

Chest Roentgenogram and Related 
X-Ray Radiation Effects 

The chest x-ray continues to be an important part of all tuberculosis 
casefinding progranns and an important and dependable tool in early diagnosis 
of unsuspected chest disease. 

In June of 1956, the National Academy of Sciences, National Research 
Council, called attention to the Biological Effects of Atomic Radiation, espec- 
ially as it affects the human body and its reproductive organs. Later reports 
discussed the possibilities of effects of body radiation upon the blood system 
with leukemia as a delayed effect. 

This discussion on radiation effects has led everyone — scientists, phys- 
icians, and laymen — to think deeply concerning them and to weigh the benefits 
from x-ray diagnostic procedures against the liability of harmful effects of 
radiation. Most factual information on this aspect of low doses of ionizing 
radiation has come from aninnal experimentation. 

In people who are ill, the needs for radiological studies are great and 
the diagnostic benefits outweigh the possibly hazardous effects of radiation. 
All radiation exposure that serves no useful purpose should be scrupulously 
avoided. 

That no standard pattern of radiation exposure is delivered by any 
standard type of x-ray machine is well recognized. Each x-ray unit must 
be provided with all necessary safety devices for minimizing gonadal and 
general body radiation. This must be done by persons trained in radiologi- 
cal protection. 

•Nho Should Get X-Rays ? 

The American Trudeau Society has emphasized that chest roentgeno- 
grams are justified only if they lead to the detection of previously unsuspec- 
ted or clinically significant, curable lung disease, followed with appropriate 
therapy. If abnormal chests are not followed up, radiation has been wasted. 
Therefore, it is essential for those engaged in the detection of pulmonary 
disease to evaluate their yields. Among certain population segments in which 



36 Medical News Letter, Vol. 32, No. 6 



there are high yields, periodic chest x-rays are the most practical approach. 
Among infants, children, young adults, prenatal patients, and especially 
young diabetics, the tuberculin test should be used as the preliminary screen- 
ing technique whenever possible and the tuberculin reactors should have x-ray 
examinations of the lungs. However, aside from screening, every child 
should have a single x-ray film for the identification of congenital or devel- 
opmental defects and nontuberculous disease and for comparison with any 
films taken later in life. Only those x-ray units that meet modern require- 
nnents for radiation protection should be used. 

vVhat Type of Apparatus Should be Used? 



Other factors being equal, the amount of radiation necessary for a 
satisfactory chest film is least with a standard 14 x 17 film in a cassette with 
intensifying screens. In comparison, there is approximately 3 to 5 times 
more radiation using the mirror optics photofluoroscopic unit and about 10 
to 20 times the radiation exposure when using the standard lens camera 
photofluorographic machine. This is still a very small amount of radiation, 
but these figures may be multiplied by 100 if the apparatus is not properly 
equipped with protective devices. 

Where the number of survey films taken is small or when modern 
protective devices have not been installed, it is better to use standard 14 x 
17 films, even at a higher cost. Where the number of films taken per day is 
large or the machine n:ust be moved frequently, a properly equipped photo- 
fluorographic luiit is the most practical apparatus. The increased amoxmt. 
of radiation involved is small and is warranted where the yield of new cases 
is significant. 

Whenever a new photofluorographic unit is purchased, the newer mirror 
optical system camera is to be preferred over the ordinary lens system even 
at greater cost. Screening of groups by fluoroscopy should be discouraged 
because the results are not accurate enough for diagnostic purposes; there is 
no permanent film record of the examination and the radiation exposure in- 
volved is excessive. 

The Nature of Radiation Effects 

Populations are being exposed to a variety of radiations from natural 
and artificial backgrounds as well as from medical examinations. Exposure 
received by the population today from all sources appears to be at a lower 
level than that which has produced harmful effects in humans and experimen- 
tal animals. Those responsible for screening programs should insure that 
the radiation dose is maintained at the lowest practicable level both to those 
being examined and to equipment operators. 

Conclusions . The kernel of the problem of radiation effects is the 
awareness by the public, physicians, and tuberculosis workers that the whole 
subject is one of weighing the benefits of radiography against the known and 
unknown effects of radiation exposure. It should remain clear that radiation 



Medical News Letter, Vol. 32, No. 6 37 



which serves a useful and necessary purpose is warranted, but it should .« 

be used with the best protective devices. Putting the chest x-ray examina- 
tion in its proper perspective, the radiation exposure to the gonads or body 
from a single chest film using a well monitored machine is infinite sinnal 
when conrtpared to the connmonly used x-ray diagnostic procedures directly 
involving the gonadal areas. 

Recommendations. Several specific recommendations from this report 
can be made to the constituent associations of the National Tuberculosis Assoc- 
iation and American and State Trudeau Societies. 

1. Chest x-ray surveys must be continued in the field of tuberculosis, 
in the detection of cancer, industrial thoracic disease, acute and chronic non- 
tuberculosis infections, chest tumors, and cardiovascular abnormalities. 

2. Conventional and photofluorographic x-ray \mits with adequate pro- 
tective devices may be used to survey segments of the population which are 
expected to show a high yield of thoracic disease. 

The installment of certain protective devices should be made now. 
These include proper cones, proper filtering, shielding devices for subject 
and operator, and exposure controls of an automatic nature. 

3. Tuberculin testing in infants, children,, young adults, prenatals, 
and yoting diabetics should be developed as a primary guide to tuberculosis 
contacts and as one case-finding method, limiting x-ray of the chest to those 
with a positive tuberculin test. 

4. Case -finding programs shouldbe reassessed to determine those 
segments of the population most deserving of chest x-ray surveys or tuber- 
bulin testing, 

5. The instruction and training of personnel should include information 
concerning the protective devices for all types of x-ray units. 

6. It should be made known to health workers and the public that effec- 
tive steps have been taken to minimize radiation exposure involved in taking 
chest x-rays. The need for early diagnosis and treatment of all forms of 
pulmonary disease should be ennphasized. 

7. Members of the American Trudeau Society and constituent associa- 
tions of the National Tuberculosis Association naight well pronnote the training 
of personnel skilled in radiation protection. The leadership of these organiza- 
tions in the field of thoracic disease would help to assure the public that rad- 
iation exposure is at a minimum and that protection is maximum wherever 
chest x-ray exanriinations are conducted under their sponsorship. (Executive 
Committee, American Trudeau Society, Chest Roentgenogram and Chest Roent- 
genographic Surveys Related to X-Ray Radiation Effects and Protection from 
Radiation Exposure: Am. Rev. Tuberc. , February 1958; abstracted in Tuber- 
culosis Abstracts, Nat. Tuberc, A., XXXI : 7, July 1958) 



38 



WHAT YOU SHOULD KNOW ABOUT. . . 



USE OF 



TO make a safe turn in the old days a driver just put his 
arm out the window. But when his wife came up with 
electric gadgets that took "drudgery" out of housework 
and "dishwater" out of hands, he wanted something to 
take the arm out of signaling. To free him from the coarse 
red highway hand — auto makers came up with . . . 



BRIGHT mechanical turn signal lamps. In the change- 
over, safe driving — in many instances — was short cir- 
cuited. Some drivers now cruise along, their turn signals 
flashing, >vithout any intention of turning. This makes 
the driver behind nervous. Turn signals should speak 
clearly — reassuringly. Here's the way. 




I \ 



'Mil 



T 

u 

R 
N 

S 
I 

G 
N 
A 
L 
S 



KNOW THE LAW 

Most states and cities hove adopted turn signal laws 
in conformance with the Uniform Vehicle Code. The 
UVC lists these rules for turning: 



post to the left outside limit of the vehicle body 
exceeds 24 inches; the distance from center of top 
of steering post to rear limit of vehicle body or 
load exceeds 14 feet. 



GET IN POSTION 

Don't turn unless you can do it with reasonable 
safety. That means you must look ahead, decide 
where you wont to turn and be in a position fo 
turn when you get there. This applies to intersec- 
tions, traffic lanes, private roadways and drive- 
ways, and passing cars. 



YIELDING THE RIGHT-OF-WAY 

Driver intending to turn left who is already within 
intersection should yield right-of-way to approach- 
ing vehicles within intersection or close enough to 
be a hazard. Having yielded right-of-way, driver 
may then turn and any approaching vehicles 
should yield right-of-way. 



MAKE THE SIGNAL IN ADVANCE 

Give a continuous signal for a distance of at. least 
100 feet before fuming. 



• DON'T SURPRISE 

Don't stop or suddenly decrease speed without 
giving an appropriate signal unless there's an 
emergency. 



DRIVERS SHOULD ALSO: 

■ Be alert for unexpected actions of other drivers. 

■ Make sure they don't behave unexpectedly them- 
selves; flashing turn signals to change lanes is not 
enough — check traffic first. 

■ Check mechanical turn signals periodically fo be 
sure they're working. 

■ Make certain turn signals are not flashing when 
there is no intent to turn. 



• KEEP YOUR HANDS 

There's no law against using your arm and hand 
to make a turn signol. But signal lamps are re- 
quired when: the distance from top of steering 



GOOD RULE AT INTERSECTIONS 

Any pedestrian or vehicle in, or about fo enter, in- 
tersection has righf-of-way over vehicle makinp 
the turn. 



HOW TO MAKE LEFT TURN 



39 



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-<- ON TWO-LANE ROAD 



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Driver moves to extreme left of 
lane fo make turn; thus he warns 
other motorists that he intends to 
turn left. At leost 100 feet before 
turning he starts giving continuous 
turning signal and slows down. 



-<- ON FOUR-LANE ROAD 



Turn must be made from left lane; 
thus driver should plan transfer 
from traffic lane in advance of 
turn, making it with extreme care 
and signaling if necessary. At 
least 100 feet before turning he 
starts giving continuous turning 
signal and slows down. 







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TURNING 



*Don't turn too soon. Driver must 
keep to right of center line at cross 
walk of street he is leaving. 



*When driver leaves intersection 
after turning he should enter to 
right of center tine of roadvvay. 



*When possible the left turn 
should be made to the left of the 
center of intersection. 



*Remember — any pedestrian or 
vehicle in or about to enter the in- 
tersection has right-of-way over 
vehicle making turn. 



\ WHEN PASSING 

Cars A, B and C are traveling 
about 40 m.p.h. on a 4-lane di- 
vided highway with posted speed 
limit of 45 m.p.h. To pass A the 
driver should: 

■ Make sure there's enough road- 
woy between B and A 

■ Then signal informing B ond C 
he intends to pass A and will 
be in their lane. 



FOR RIGHT TURN— observe 
same general rules, but keep 
as close to right as possible 
when approaching intersection 
and when turning. 



( T raffic Safety, September 1958) 



40 



Medical News Letter, Vol. 32, No. 6 



Policy 

The U. S, Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention o£ officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Departnraent of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

;}: 3^ :{c :^ 3ic :{c 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, Eind old and new 
addresses. 

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